The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review

Man running up gradients

Today sees the opening of the Physiotherapy UK Conference, which is the Chartered Society of Physiotherapy’s new flagship annual event. Unsurprisingly, the programme in the musculoskeletal theme contains several presentations related to back pain. Seeing as this is still back pain week, I thought that I would continue from my previous blog about Yellow Flags and focus on Graded activity (GA), an intervention that can be used to address Flags such as kinesiophobia and/or psychological distress.

A systematic review by van der Giessen et al (2012) seemed to fit the bill for this, which assessed the efficacy of GA as treatment for non-specific acute, sub-acute and chronic low back pain (LBP) in adults, on pain, disabilities and rate of return to work.

Here’s what they did

A database search of PubMed, Embase, CINAHL and the Cochrane Library was conducted from inception until July 2011. All published randomised controlled trials (RCTs) into measuring the effect of GA in patients with non-specific LBP were eligible for inclusion. The methodological quality of each included study was determined using the (PEDro) score and a best evidence synthesis was used.

Here’s what they found

From an initial 155 articles found via the searches only 10 met the inclusion criteria. These articles reported on only five studies, wtih sample sizes from 108-223 participants. All the studies received PEDro scores of at least 7/10. Each study used operant conditioning, measured functional capacity, provided back school education and an individual sub-maximal gradually increasing exercise programme. The durations and the frequencies of the GA intervention differed, with the length of the programmes varying between 6-13 weeks. No statistical significant differences were found between GA and usual care for back pain disability, and there was conflicting evidence for the return to work rate.

The authors concluded

man lifting weights

“The best-evidence synthesis established that there is no or insufficient evidence for a positive effect of GA on pain, disabilities and the return to work rate.”

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

On the one hand, the conclusion of this review seems a bit disappointing, however, on the other hand, perhaps it’s encouraging that ‘usual care’ appears to have similar benefit to a graded activity programme. I think the authors of this review raise an important point when measuring the impact of GA – ensure that outcome measures are measuring at the levels of activity and participation, and avoid focussing the patient towards pain. I also think it would be worth focussing more on the impact of graded activity on return to work, as for this outcome there were conflicting findings.

On another note…if you happen to be visiting the Physiotherapy UK Conference, please pop along and support me  on Saturday evening when I will be pitching (with my Elf hat on) in the Dragon’s Den!

What are your experiences in delivering graded activity programmes? Have you done your own evaluations? 

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.


van der Giessen RNSpeksnijder CMHelders PJ. (2012) The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review. Disability & Rehabilitation, 34(13):1070-6. [PubMed abstract]


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